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Labor Epidural - Labor Epidural Analgesia Dmitry Portnoy MD...

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Labor Epidural Analgesia Dmitry Portnoy, MD Anesthesiology Department
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The Physiology of Pain in Labor 1 st stage of labor – mostly visceral Dilation of the cervix and distention of the lower uterine segment Dull, aching and poorly localized Slow conducting, visceral C fibers, enter spinal cord at T10 to L1 2 nd stage of labor – mostly somatic Distention of the pelvic floor , vagina and perineum Sharp, severe and well localized Rapidly conducting A-delta fibers, enter spinal cord at S2 to S4 T 10 L 1 S 2 S 4 http://www.manbit.com/oa/oaindex.htm
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The Intensity of Pain in Labor http://www.manbit.com/oa/oaindex.htm
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Boundaries of the Epidural Space Superior - the foramen magnum Inferior limit - the sacral hiatus and sacro-coccygeal membrane Anterior - the posterior longitudinal ligament covering the bodies of the vertebrae and the intervertebral discs Posterior - periosteum of laminae of the vertebrae and the ligamenta flava Lateral – periosteum of the pedicles and intervertebral foraminae From Cousins, Neural Blockade
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Spread of Epidurally Injected Solutions Epidurally administered drugs must travel through: dura matter arachnoid matter CSF pia matter white matter gray matter Rapid access via “dural cuff” Competing pathways: Uptake into epidural epidural fat Uptake into systemic circulation From Cousins, Neural Blockade
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Indications for LEA 1. PAIN EXPERIENCED BY A WOMAN IN LABOR 2. When medically beneficial to reduce the stress of labor ACOG and ASA stated “ in the absence of a medical contraindication, maternal request is a sufficient medical indication for pain relief…” Points of controversy When? Who? How?
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Contraindications for LEA ABSOLUTE Patients refusal Inability to cooperate Increased intracranial pressure 2 mass lesion Infection at the site of needle placement Frank coagulopathy Severe hypovolemia Inadequate training RELATIVE Systemic maternal infection Preexisting neurological deficiency Mild or isolated coagulation abnormalities Relative (and correctable) hypovolemia Poor communication
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We are All Ready…Now What? - Last Check!
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Labor Epidural - Labor Epidural Analgesia Dmitry Portnoy MD...

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